Request for Access to Health Information Held by the ...



89027028956000Health Information Data Request FormInstructions: This form is to be completed when requesting data held by Manitoba Health, Seniors and Active Living (MHSAL) including aggregate, de-identified (anonymized) data. See definitions below.Filling out the form in MSWord: Using the tab or arrow keys, the cursor will advance to the next input field, with the document text being protected from inadvertent changes. Checkboxes may be checked by clicking with a mouse, using the space bar, or entering an 'x'. Once completed, save the document, print, sign, and fax or mail to the appropriate MHSAL branch (addresses are listed on the last page of the form). If you have questions or require further information regarding data content, please contact the appropriate Manitoba Health, Seniors and Active Living program area listed on the last page of this form.Definitions: Aggregate Data: Aggregate data present the total number of occurrences within a defined population (stratified by age, gender, or geographic area) or over a given time period. Administrative health data can only be presented in aggregate form for the purposes of reporting or publication with cell sizes of at least five (5) or more (smaller rates of occurrence or cell sizes must be suppressed). Line-level Data: Data at the individual level. This is considered Personal Health Information as defined in The Personal Health Information Act (C.C.S.M. c. P33.5):“Personal Health Information means recorded information about an identifiable individual that relates to(a) the individual’s health, or health care history, including genetic information about the individual,(b) the provision of health care to the individual, or (c) payment for health care provided to the individual,and includes(d) the PHIN and any other identifying number, symbol or particular assigned to an individual, and(e) any identifying information about the individual that is collected in the course of, and is incidental to, the provision of health care or payment for health care; “Data (unspecified): Refers to both aggregate and line-level data provided through this request and agreement. It does not include statistical and/or analytical tables generated as a result of data analysis.Transformation Project: Refers to a project that is being conducted as part of the Health System Transformation and has been approved by the Transformation Leadership Team.I. General InformationDate of Request (YYYY/MM/DD): FORMTEXT ?????Name (to whom all correspondence will be addressed): FORMTEXT ?????Affiliation or Organization: FORMTEXT ?????Address: FORMTEXT ?????Email: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????II. Planned Use of the Information (a) Please provide a general description of the planned use of the information, including its purpose and the proposed analytical methodology. (This may be added as an attachment FORMCHECKBOX check here if attachment) FORMTEXT ?????(b) Will the data be used for the purpose of creating a report or publication? Yes FORMCHECKBOX No FORMCHECKBOX If yes, please specify. FORMTEXT ????? (c) Is this request part of a Transformation Project?Yes FORMCHECKBOX No FORMCHECKBOX If yes, please specify. FORMTEXT ????? (d) Has this request been formalized through a written agreement with MHSAL (e.g. Letter of Agreement (LOA), Memorandum of Understanding (MOU), Memorandum of Agreement (MOA), or a Data Sharing Agreement (DSA)? Yes FORMCHECKBOX No FORMCHECKBOX (If yes, please attach)(e) If a third party consultant is to receive the data (in accordance with the requirements of the Personal Health Information Act or the Freedom of Information and Protection of Privacy Act), are the necessary authorities and/or agreements in place?Yes FORMCHECKBOX No FORMCHECKBOX (If yes, please attach)III. Specific Data Required (a)Please list the specific data elements and years of data required, and/or the variables of interest. Please be as specific as possible as the Personal Health Information Act requires that only the minimum information necessary be released. Datasets Required (if known)Data Elements Required (field names, variables, etc.)Years of Data Required FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? to FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? to FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? to FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? to FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? to FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? to FORMTEXT ?????* Note: Fiscal years are from April 1st, YYYY through March 31st, YYYYInclusion/exclusion criteria (e.g. age, gender, region of residence, diagnoses, etc.) FORMTEXT ?????Other relevant information: FORMTEXT ?????Please indicate when you are expecting to begin analyses. FORMTEXT ?????Note: Data extractions by MHSAL are performed on a priority basis and meeting your timelines cannot be guaranteed. Once your request is received and the programming time required for the extraction determined, an estimated delivery date will be provided.IV. Data Security If line-level data is being requested:(a) Please indicate where the data will reside.Address (including room/office number if applicable): FORMTEXT ?????(b) How will the confidentiality of the data be protected? Please include a discussion of the security measures, how and when the data will be destroyed, and other relevant data protection issues. Be specific and use as much space as necessary. FORMTEXT ?????V. Other Information Please describe any other information relevant to this application. FORMTEXT ?????VI. AgreementBy signing this request, the applicant agrees to the following:(a) the Data is principally required for the purposes of health care planning, program evaluation, health surveillance, and or quality assurance analyses.(b) all reports and/or scientific publications resulting from the analyses of these Data will be submitted to MHSAL for review at least thirty (30) days prior to the document being submitted for publication. MHSAL will review the report/publication for appropriate representation of the Data and to ensure there are no confidentiality violations or potential identification of individuals for whom Data has been provided. MHSAL reserves the right to prohibit the publication of any report which upon review is found to contain inaccurate data or data presented in a form that may potentially identify individuals.(c) the Data will not be copied or accessed for a third-party or for any purpose other than that outlined in this application. (d) the Data will not be disclosed to a third-party. the Data will not be used to contact, directly or indirectly, any individual the information is about for any purpose.________________________________________________________________DateSignature of Person Making Request________________________________________________________________DateSignature of Person Making RequestOffice Use Only:Data Request File Number: FORMTEXT ?????Received on: FORMTEXT ?????Cost-recovery required? Yes FORMCHECKBOX No FORMCHECKBOX Estimate: $ FORMTEXT ?????Expected Completion Date: FORMTEXT ?????Supporting documentation:MOU FORMCHECKBOX LOA FORMCHECKBOX MOA FORMCHECKBOX DSA FORMCHECKBOX N/A FORMCHECKBOX FORMCHECKBOX Approved FORMCHECKBOX Not Approved - Specify reasons: FORMTEXT ????? FORMCHECKBOX Conditionally Approved - Specify conditions: FORMTEXT ?????______________________ _________________________________DateSignature of Program or Branch Director(with approval authority)Programmer: FORMTEXT ?????Actual Completion Date: FORMTEXT ?????When submitting your request, please send to the appropriate MHSAL Contact:Information Management & AnalyticsInformation Management & AnalyticsManitoba Health, Seniors & Active Living300 Carlton StreetWinnipeg MB R3B 3M9Phone: (204) 786-7139Fax: (204) 944-1911Information.Analytics@gov.mb.ca Public HealthInformation Management & AnalyticsManitoba Health, Seniors & Active Living300 Carlton StreetWinnipeg MB R3B 3M9Phone: (204) 786-7139Fax: (204) 944-1911Information.Analytics@gov.mb.caCadham Provincial LaboratoryDr. Paul Van CaeseeleMedical Director, Cadham Provincial Laboratory750 William AvenueWinnipeg MB R3C 3Y1Phone: (204) 945-6456Fax: (204) 786-4770Paul.Vancaeseele@gov.mb.caProvincial Drug ProgramsDr. Patricia CaetanoExecutive Director, Provincial Drug ProgramsManitoba Health, Seniors & Active Living300 Carlton StreetWinnipeg MB R3B 3M9Phone: (204) 786-7333Fax: (204) 957-0262Patricia.Caetano@gov.mb.ca ................
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